How soon after angioplasty of a coronary artery with stent placement can Plavix (clopidogrel) be held?

Duration of Dual Antiplatelet Therapy After Coronary Artery Angioplasty with Stent Placement

For patients who have undergone coronary artery angioplasty with stent placement, Plavix (clopidogrel) should be continued for at least 12 months after drug-eluting stent (DES) implantation and for at least 1 month (ideally up to 12 months) after bare-metal stent (BMS) implantation. 1

Duration of Dual Antiplatelet Therapy Based on Stent Type

• For bare-metal stents (BMS): Clopidogrel 75 mg daily should be given for a minimum of 1 month and ideally up to 12 months if patients are not at high risk of bleeding 1
• For drug-eluting stents (DES): Clopidogrel 75 mg daily should be given for at least 12 months 1
• For specific types of drug-eluting stents:
  • Sirolimus-eluting stents: Minimum of 3 months, ideally up to 12 months 1, 2
  • Paclitaxel-eluting stents: Minimum of 6 months, ideally up to 12 months 1, 2

Risk Stratification and Individualized Duration

• If the risk of morbidity from bleeding outweighs the anticipated benefit of continued P2Y12 inhibitor therapy, earlier discontinuation (less than 12 months) may be reasonable 1
• Minimum durations if bleeding risk is high:
  • Bare-metal stents: Minimum 2 weeks 1
  • Drug-eluting stents: Minimum 3-6 months depending on stent type 1, 2

Aspirin Recommendations

• After completion of dual antiplatelet therapy, aspirin should be continued indefinitely at a dose of 75-162 mg daily 1
• Lower-dose aspirin (81 mg daily) is reasonable for long-term therapy to reduce bleeding risk 1

Risks of Premature Discontinuation

• Early discontinuation of clopidogrel (within the first 6 months after DES placement) is a major predictor of stent thrombosis 3
• Premature discontinuation of dual antiplatelet therapy significantly increases the risk of late stent thrombosis, which can lead to myocardial infarction and death 1, 3

Special Considerations

• For patients requiring non-cardiac surgery:

  • Surgery should be deferred until patients have completed an appropriate course of dual antiplatelet therapy 1
  • If surgery cannot be delayed, aspirin should be continued if at all possible 1
  • The thienopyridine (clopidogrel) should be restarted as soon as possible after the procedure 1

• For patients on triple therapy (including warfarin):

  • Use of warfarin in conjunction with aspirin and clopidogrel increases bleeding risk and should be monitored closely 1
  • Consider a target INR of 2.0-2.5 with low-dose aspirin (75-81 mg) and standard clopidogrel (75 mg) 1

Common Pitfalls and Caveats

• Discontinuing dual antiplatelet therapy prematurely is one of the most significant risk factors for stent thrombosis, particularly with drug-eluting stents 1, 3
• The risk of stent thrombosis extends beyond the traditional recommended durations, especially for drug-eluting stents, so clinicians should remain vigilant even beyond 365 days after DES placement 1
• Patients should be counseled on the importance of compliance with dual antiplatelet therapy before stent implantation 1
• Patients should be advised not to discontinue antiplatelet therapy without discussing with their cardiologist 2